# National Serv**ice Trust Enrollment Form** Completion of this form is required to enroll a serving member in the National Service Trust, m aking the member eligible for a Segal AmeriCorps Education A

ward upon successful completion of his or her term of service. It also provides the Corporation for National and Community Service (CNCS) with basic demographic data. 

## PA**RT 1 Member: Please Complete and Sign**  **1. Name**  Last First MI 

### 2. **Date of Birth**  **3. Social Security Number** Month Day Year 

### 4. **Citizenship Status**

I am a U.S. Citizen or National * I am a Lawful Permanent Resident Alien of the United States ** I am an Asylee ***

* Citizens of the US include persons born in Puerto Rico, Guam, the US Virgin Islands, and the Northern Mariana Islands. Natio nals of the US include persons born in America Samoa, including Swains Island. **Generally, you are a Lawful Permanent Resident Alien of the US if you are a US permanent resident with (i) a Permanent Resident Card, USCIS Form I 551; (ii) an Alien Registration Receipt Card, USCIS Form I - 551, (iii) a passport indicating that the USCIS has approved it as temporary evidence of lawful a dmission fo r permanent residence; or (iv) a form I - 94 indicating that the USCIS has approved it as temporary evidence of lawful admission for permanent residence. NOTE: A student visa does not confer eligibility to enroll in an AmeriCorps program. *** You are an asylee if you have a Form I - 94 with asylum granted stamp; form I
- 766 with Category “A5”, “A05”, or “A
- 5”; or an Order of the Immigration Judge granting asylum. 

### 5. School Status Wh at is the highest level of education you have completed? Less than high school High school diploma/GED Technical school/apprenticeship/vocational Some college Associates degree (AA) College graduate Graduate degree (e.g. MA, PhD, MD, JD) 

### If you have not completed a high school diploma or its equ ivalent:

I agree to obtain a high school diploma or its equivalent before using my educational award, and I did not drop out of elementary school or secondary school to enroll in the program. **If y ou have some college:** 

**Choose the most recent school**  **yo u attended**  **Choos e On**  **e** I f school is not listed, provide name here Type of degree, diploma, or certificate **Choos e One**  **If y ou have an A** 

**ssociate’s degree: Choose the school from which y**  **ou received yo**  **ur most recent A ssociate’s degree**  **Choos e On**  **e** If school is not listed, provide name here Type of degree, diploma, or certificate **Choos e On**  **If y ou have a Bachelor’s degree:**  **Choose the school from which y ou re**  **ceived y our most recent Bachelo**  **r ’**  **s degree Choos**  **e On e** If school is not listed, provide name here Type of degree, diploma, or certificate **Choos e One**  **If y ou have a graduate degree:**  **Choose the school from which y ou received y** **our most recent graduate degree Choos**  **e On e**  If school is not listed, provide name here Type of degree, diploma, or certificate **Choos e One** 



### 6 **. Current Address**  (All information will be sent to you at th is address until you notify CNCS of a change of address.) Number and Street City State Zip Code Email Address Home Phone Business Phone Ext 

### 7 **. Permanent**  **Address** (Name and address of person through whom you can always be reached once you leave the program.) 

### Check here if same as current address

. Last First MI Number and Street City State Zip Code Email Address Home Phone Business Phone Ext 

### 8 **.** Have you prev iously en rolled in an AmeriCorps , Silver Scholar, or Serve America Fellow Program? No Yes H ow many times? 

### 9 **.** Have you ever been released 'for cause' by any AmeriCorps , Silver Scholar, or Serve America Fellow program? No Yes

. **10 . Education Award**  **Limitations. I underst and**  that I may not receive more than the aggregate value of two full
-time education awards and that upon successful completion of the term of service, I will receive only that portion of the education award for which I a m eligible, which may be all or a part of an education award, or no education award, pursuant to 45 CFR § 2526.55 

## PA**RT 2**  **Member Enrollment**  **Certification By**  **signing this enrollment form I agree**  , if asked, to provide documentation to verify the accuracy of the information I have provided in this form. I understand that a knowing and willful false statement on this form can be punished by one or more of the following: a fine or imprisonment or bot h under 18 U.S.C. § 1001, exclusion from participation in federal programs, and forfeiture of benefits I may receive as a result of my enrollment or other actions authorized by the Civil Fraud Remedies Act, 31 U

. S

. C

. §§ 3801 - 3812

. 

### Member’s Signature **Date**

## PA**RT 3**  **Member: Please A nswer the Following Questions**  CNCS gathers information about sex, race, ethnicity, and disability status to ensure opportunities are provided to serve for people of all conditions. This information will solely be used for data analysis. The information you provide will not be used in any way to determine or affect any federal benefit. Providing this informati on is optional. If you do not wish to answer, please check “Prefer not to respond.” Wesincerely hope that you will answer these questions to assist us in analyzing our ability to serve all Americans equally

. **1. What is y** **our sex**  **?** Female Male **2. Are**  **yo u registered to vote?**  Yes No Not sure Not eligible Prefer not to respond **4 .**  **Which of the following categories best describes y our racial origin**  **? (check all that apply** **)** American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Black or African American Wh ite Asian American Other Prefer not to respond **5 .**  **Which of the following categories best describes y our ethnic origin?**  Hispanic or Latina/o Not Hispanic or Latina/o Prefer not to respond **6 .**  **What is y our Military** **, Veteran, or Family member Status**  **? (check all that apply** **) Note: All Honorably** 

**Discharged Veterans Qualify for Nomination for the Presidents Volunteer Service Award.**  I am a Veteran I am an Active Duty Member of the U.S. Armed Forces I am a Member of the National Guard or Reserve Component I am an immediate family member of a Veteran I am an immediate family member of an Active Duty Member of the U.S. Armed Forces I am an immediate family member of a National Guard Member or Reservist I am not in the military, a veteran or a family member of someone in the US. Armed Forces Prefer not to respond **7. What is y** **our best estimate of yo**  **ur household’s income for the past 12 months**  **?** Under $1 0,000 $ 10,000 to $19,999 $ 20,000 to $29,999 $ 30,000 to $39,999 $40,000 to $49,999 $ 50,000 to $59,999 $ 60,000 to $69,999 $ 70,000 to $79,999 $ 80,000 to $89,999 $ 90,000 to $99,999 $100,000 or more Prefer not to respond **8 .**  **Do yo**  **u receive Social Security disability**  **benefits, such as Supplemental Security Income (SSI) or Social Security**  **Disability Insurance (SSDI)?** 

Yes No Prefer not to respond **9 .**  **How did y** **ou hear about this program? (check all that apply .)** 

o Recruitment brochure o College Resource Fair o Facebook ad or on Facebook in general o Twitter o Other social media platform. Please specify:

_____________________ o AmeriCorps online recruitment system o J ob search W eb page o Article (online, newspaper, or magazine) o Advertisement in a newspaper/magazine o Guidance counselor/teacher o Parent/relative o Current or former AmeriCorps Member o Friend o TV commercial o Radio commercial o AmeriCorps recruiter/representative o Recei ved information in the mail o AmeriCorps program poster o Other. Please specify:

### For **Official Use Only**

**For Official Use Only Public reporting burden**  -- Estimated time to complete this form, including time for reviewing instructions and gathering and providing the information n eeded to complete the form, is 3 minutes for the Member section and 4 minutes for the Certifying Official section. S end commen ts regarding this burden or the content of this form to: C orporation for National and Community Service, National Service Trust, 1201 New York Avenue, NW , Wa shington, DC 2 0525

. CNCS informs the potential persons who are to respond to this collection of i nformation that such persons are not required to respond to the collection of information unless it displays a currently vali d OM B control number on this page of the form (see 5CFR 1320.5(b)(2)(1)) **Privacy Statemen**  t -- In compliance with the Privacy Act of 1974, the following information is provided: The collection of this information is authorized by t he provisions of the Nation al and Community Service Act of 1990, as amended . The primary purpose of the information is to successfully enroll a member in a t erm of service and the education award program. The evaluative information will help CNCS improve its programming and services to members. Information may be shared with other agencies, such as the Social Security Administration, through computer matching agreements for the purpose of verifying identity and citizenship status information provided by you in this document. In furtherance of CNCS’s efforts to ensure that the programs are inclusive of persons with disabilities, your Social Security Number may b e released to the Social Security Administration to measure aggregate statistical data on the number of AmeriCorps members receiving disability- based benefits. Information may also be provided to federal, state, and local agencies for law enforcement purposes. The Internal Revenue Service has determined that the education award is taxable in the year it is used. Your Social Security Number (SSN) is solicited under the authority of the Internal revenue Code (26 U.S.C. 6011(b) and 6109) for use as a taxpayer identification number. Failure to disclose the SSN or any other information may result in a denial of your receiving an education award or it may delay the processing of your educatio n award. OM B Approval No.: 3045 - 0006

### For **Official Use Only**

**For Official Use Only** 

## PA**RT 4**  **Enrollment Certify** **ing Official: Please Complete and Sign 1.**  **Program:** AmeriCorps State & National:

AmeriCorps National Direct AmeriCorps State AmeriCorps Education Award Program AmeriCorps Tribe AmeriCorps Territory AmeriCorps VISTA AmeriCorps National Civilian Community Corps AmeriCorps Serve America Fellows Other (Specify): **2. Ty** **pe of Enrollment** (Mark only one.)

Full -time (1700 hours per year, or 365 days per year for VISTA) VISTA Summer Associate (10
- 12 weeks) Half
-time (900 hours in no more than 2 years) Half
-time (900 hours in no more than 1 year) Reduced half
-time 675 hours Quarter time 450 hours Minimum time/Summer 300 hours **3. Will the member receive a living allowance?** 

Yes No
**4. Educational A** 

**ward Amount:**


### 5 **. Program Information**  Name of Program or AmeriCorps NCCC Campus 

### Operating Site I.D. Number Number and Street City State Zip Code Business Phone Ext I understand that a knowing and willful false statement on this form can be punished by a fine or imprisonment or both under Section 1001of Title 18. U.S.C or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801
- 3812

. 

### Signature of Certif

**ying Official Date**  **Name of Certifying Official (Please Print):**